The Secret Language of Doctors
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Doctors call obese patients whales because they aren’t being taught that obesity is a disease. They aren’t given equipment to transport bariatric patients safely. They aren’t given the tools to operate on these patients effectively. Instead of banning the slang, why not provide the education and support needed to diagnose and treat bariatric patients?
Instead of condemning slang such as cockroach and frequent flyer, teach ER physicians and nurses to attack the underlying reasons patients visit ERs over and over and over again. Better still, if the ER isn’t the best place to manage superutilizers, then follow my colleague Dr. Jeff Brenner’s lead and find one that’s better.
If ERs have trouble with geriatric and psychiatric patients, then maybe the solution is to give such patients ERs of their own.
On January 24, 2013, a 32-year-old woman was taken by paramedics to the ER at Gila Regional Medical Center in Silver City, New Mexico. According to a story in the Silver City Sun-News, the woman’s mother called 911 at 9:30 p.m. and told the dispatcher her daughter was suicidal and had a gun. When the woman was brought to the ER, her clothes were taken off and a female nurse searched the woman, but did not find a weapon. Shortly after, the woman pulled out a gun and shot herself.
Mona Shattell says the Silver City incident is not the only one. In a Huffington Post blog entry from February 4, 2013, Shattell, a professor in the School of Nursing at DePaul University in Chicago, wrote that in September 2012, a man shot himself outside an ER in Wichita, Kansas; a month earlier, a man in Stillwater Oklahoma killed himself in an ER restroom.
“Had these individuals instead gone to a psychiatric emergency room, or one of a few [in the U.S.] specially designed and staffed, non-clinical settings for persons in emotional crisis, their deaths may have been prevented.”
The stakes may not be as high for elderly patients, but a movement to build ERs that specialize in geriatric patients is likewise underway in America.
Better places for undesirable patients, better training and better equipment only go so far. The greater challenge is how to get young doctors to want to treat them. I’m afraid fixing that is a long-term project. Medical schools need to recruit students who love caring for the patients we invent slang to describe. While they’re at it, both medical schools and hospitals need to recruit leaders and other role models who enjoy caring for twenty-first-century patients.
If doctors don’t take up the call, then the other solution is to find different health professionals who like these patients more than doctors do. In both the U.S. and Canada, young doctors just finishing their residencies are increasingly finding it difficult to secure jobs. The phrase unemployed doctor—once considered an oxymoron—has become a reality.
Nurse practitioners (NPs) are registered nurses who have taken additional postgraduate training that enables them to have an enhanced scope of practice that includes diagnosing and treating patients, ordering tests and prescribing medications. NPs are salivating at the chance to pick up the slack.
And while we’re at it, I think much of the slang directed by one group of doctors toward another goes back to a fundamental problem: we don’t empathize with one another because we don’t spend a moment thinking about the challenges other kinds of doctors face. One way to reduce that is to have doctors spend time working in other parts of the hospital.
If I were in charge, I’d retire the slang police. I wouldn’t encourage slang, but I certainly wouldn’t tell young doctors to keep it to themselves. Instead, I’d listen for it, and especially listen for trends that indicate problems in the local hospital culture that need to be addressed.
I suspect that Vineet Arora already does that. I’m not so sure about other proponents of medical professionalism.
* * *
In writing The Secret Language of Doctors, one of the things I set out to do was to figure out the impact women are having on the use of medical slang and the attitudes behind it. It’s no secret that more and more women are becoming doctors. A growing number of medical schools have student bodies that are more than half female.
Are female doctors less likely than their male counterparts to use slang? Not based on what residents have told me as I’ve researched this book. I talked to several male residents who felt that women in medicine are just as likely to invent and use slang as their male counterparts. The women I spoke to seem to agree.
“I think we like to think we’re different,” says a female resident in OBGYN. “But I don’t think we really are. I think we don’t use as much sexually based slang, but the slang we use is every bit as dark as what the men use.”
The reason is that the conditions that give rise to the use of slang have not changed—especially dealing with patients who are at a very intense time in their lives who have really high needs. The atmosphere is often charged. Not only are young doctors emotionally exhausted, they are physically exhausted as well.
“I think the pressure is huge on women, just as on men,” says the female resident in OBGYN. “Sleep deprivation in OBGYN is ridiculous. In the culture, it’s almost a competition of how long can you go without sleep. It wears down your soul and your defences.”
The only people who really understand that kind of depletion after a night on call are one’s colleagues. “The black humour comes in a lot in that case. And I have no doubt it’s every bit as much with women as it is with guys.”
Richard and Sylvia Cruess think the impact of women doctors on the use of slang can be answered only after a good deal of observation of women in the trenches. Richard Cruess says that, intuitively, women are less likely to use slang.
“I think it depends on the individual,” Sylvia Cruess adds. “There certainly are women doctors who are quite derogatory and use derogatory language.”
In my opinion, the culture of medicine is strong enough to resist a major gender shift without changing one iota.
* * *
On July 15, 2012, Korean singer-songwriter Psy posted “Gangnam Style,” a hip-hop song about life among the idle rich who live in a district of the South Korean capital, Seoul. More than 1.7 billion people have watched the video on YouTube—making it the most popular video in YouTube’s history. Since then, “Gangnam Style” has inspired hundreds if not thousands of parodies.
One such parody that caught my eye was titled OB/GYNE Style, which was written and produced by an OBGYN resident in Toronto. I liked it immediately for two reasons. First, unlike most of the “Gangnam Style” parodies I’ve watched, this one was well done. The other reason is that it’s filled with OBGYN slang terms like catching babies. The resident even says he doesn’t mind taking care of morbidly obese women with a BMI of 60.
So proud was Sunnybrook Health Sciences Centre—the hospital where the resident was working at the time the video debuted—that it posted OB/GYNE Style to its YouTube channel. The pride and glory were short-lived; Kalina Christoff, founder of Humanize Birth, a group that advocates on behalf of pregnant women, complained in the media that OB/GYNE Style was offensive. Soon after, Sunnybrook pulled the video from its YouTube channel.
“People from other obstetrical units were writing in and saying they enjoyed it and that it allowed them to take a light look at their jobs, which can sometimes be a little stressful,” Craig Duhamel, Sunnybrook’s vice-president of communications, told the Toronto Star in a story published on December 23, 2012. “We certainly didn’t want to upset anyone—it wasn’t our intention at all. While the overwhelming majority of people liked it, there were a few who were upset by it and we wanted to respect their feelings.”
In my opinion, the sin of OB/GYNE Style was not in producing it, but in sharing it without providing some context.
I, too, have shared lots of medical slang and some inside stories from the people who use slang in everyday hospital discourse. The difference between OB/GYNE Style and this book is that I’ve tried to unpack and explain the culture from
which the slang comes. I leave it to you to decide if The Secret Language of Doctors should remain in the shadows.
In my view, the major impact of medical professionalism so far is that it has made medical slang more hidden. Before, it was spoken openly in hospital elevators and corridors. Now, it’s whispered to trusted friends and colleagues. But it’s there and it continues to flourish.
Just ask Dr. Christian Jones, former chief resident in surgery at the University of Kansas Medical Center. Now embarking on a career as a surgeon and helping teach the next generation of surgical MDs, he’s proud to say he read The House of God and says absolutely he uses slang.
“Some of the medical slang has changed and some of it has not,” says Jones. “But it’s in use every day, around every patient, on every ward of every hospital. And, while The House of God was written in a somewhat different time, there are culture shifts in medicine that are too slow to make anyone think that this has entirely gone away.”
* * *
More than thirty-five years have passed since The House of God was first published. These days, the original slangmeister, Dr. Stephen Bergman, is doing a victory lap—savouring the enduring recognition he and his book have earned.
As I ended my conversation with Bergman at his home in Newton, Massachusetts, I wanted to know what he thought of the fact that thousands—perhaps millions—of physicians know about GOMERs, turfing, bouncing and many other slang terms thanks to him. “I like the fact that it helps them,” said Bergman. “I really do, because it helped me. I like the [terms] that are helpful in actually getting through the day and GOMER is one of those.”
I asked Bergman if it’s possible to use slang and still be professional.
“Well, that’s the question.” Bergman stared out the window of his office on the second floor of the carriage house where he’s still turning out novels and plays—grasping for a pithy thought. “I think you just have to get down in the dirt with what’s human. It’s like when you’re meditating. All this crap comes into your mind. You don’t say, ‘I can’t have that crap in my mind,’ because that only makes it get bigger. It is just part of being a doctor in that situation.”
Suddenly, Bergman’s eyes lit up—not the eyes of the intern who in the 1970s pulled back the curtain on hospital culture, but of the psychiatrist who spent much of his career treating patients with alcohol and drug abuse. He had one more bit of wisdom to give me.
“When you’re with someone who’s secretly an alcoholic or an addict and he or she mentions the alcohol or whatever drug, they’ll lick their lips unconsciously,” said Bergman. “You give me twenty minutes with somebody and I’ll figure out if they’re an alcoholic or not.”
I asked him if this clinical pearl has a name. He thought about it for a moment.
“I call it the Shem sign,” said Bergman, reverting to the pen name he used to write The House of God. “I’d love to publish it.”
I’m happy to have the honour—an unexpected gift from Bergman, still the slangmeister after all these years.
Acknowledgements
Following the success of The Night Shift, I cast about looking for the right book to follow it up. My proposal for a book on medical errors fell somewhat flat, as the marketplace for books on patient safety is quite crowded.
Then, Jim Gifford, my stalwart editor at HarperCollins, made a fateful suggestion. Pointing to the incredible success of the book How Doctors Think, by Dr. Jerome Groopman, Gifford suggested I consider writing a book that unpacks how doctors talk. He envisioned a light and breezy volume about the ubiquitous medical jargon that is a staple of television shows such as Grey’s Anatomy and Scrubs.
As I started my research, it soon became clear that I could use the book as an unprecedented lens with which to explore the culture of modern medicine, something I have made a career of on my CBC Radio show White Coat, Black Art.
While Gifford thought I would focus on medical jargon, it soon became clear to me that it was medical slang or argot, not jargon, that reveals what doctors think about patients, challenging situations and one another.
To discover contemporary slang, I began my search with the first purveyor of medical slang, Dr. Stephen Bergman (better known by his pen name Samuel Shem), author of the marvellous novel The House of God. Bergman filled me in on the origins of the book and the slang to which he introduced readers. As well, his reactions to contemporary slang form a critical part of my book. I am extremely grateful for his generosity and the support he lent the book.
The research for this book would not have got off the ground if not for the support and incredible networking of my friend and colleague Melissa Travis. Melissa, better known in the twitterverse as @DrSnit, paved the way for me to connect with dozens of health professionals who are also mavens of medical blogs and other avenues of social networking. These include Hood Nurse, Dr. Grumpy and Not Nurse Ratched.
I interviewed dozens of residents of all disciplines, including family medicine, internal medicine, surgery, anesthesia and obstetrics and gynecology. I am grateful to them for their contributions of slang in current use, stories that depict the emotionally charged situations in which the slang is used, and for their candid opinions on difficult patients and difficult colleagues.
I also extend my appreciation to the many attending physicians and other health professionals who gave me their time, their slang, their stories and their passion for the work they do. In particular, I’d like to single out colorectal surgeon Dr. Marcus Burnstein and obstetrician- gynecologist Dr. Raz Moola for their incredible accounts of triumph and tragedy on the front lines.
I am indebted as well to paramedic and stand-up comedian Morgan Jones Phillips, who shared some painful memories of tragedies that occurred at track level in Toronto’s subway system.
I also wish to thank Dr. Peter Kussin, a respirologist and critical care specialist at Duke University Hospital, for his stories and for his love of medical argot. I look forward to reading his book on the language of medicine.
There were times during my research that I lost my way and began to doubt the value of my work. Fortunately, at those times, I had a support crew of true believers who helped me see the importance of the book in explaining medical culture. In particular, I would like to acknowledge medical sociologists Renee Fox and Fred Hafferty, whose critical support helped sustain my enthusiasm to complete the book.
The Secret Language of Doctors is a research-intensive project. I could not have found and interviewed by myself the dozens of sources needed to flesh out modern medical argot. I am so grateful that Erin James Abra, a talented young writer and researcher, came on board as my co-investigator of slang, researcher, sometime writer, confidant and friend. Late in the process, Erin’s critical comments in response to the first draft of this book made it much better.
I also wish to thank freelance editor Shelley Robertson for fixing the tenses I got wrong repeatedly, and for her enthusiastic comments following each chapter that she edited so lovingly. In the same vein, I’d like to single out Juanita Hadwin for her fast and accurate transcriptions of the many audio interviews that Erin and I assembled in the preparation of this book. Her supportive reactions to the interviews that she transcribed kept me grounded and helped me keep my readership in mind. I am grateful to fellow author and journalist Ann Rauhala for introducing me to both Erin and Shelley.
I’m thankful to my bosses at CBC, Linda Groen, Chris Straw and Chris Boyce, for giving me a national platform on CBC Radio One to explore the culture of modern medicine. I’m also thankful to my colleagues Dawna Dingwall, Jean Kim, Kent Hoffman and Jeff Goodes, whose contributions to White Coat, Black Art enriched my understanding of the inner workings of health care.
I wish to express my gratitude to my agent Rick Broadhead, who has given me sound business advice and emotional support well before The Night Shift and up until and including The Secret Language of Doctors. His
warnings on the sophomore jinx were well taken, at least looking back.
I want to thank my editor, Jim Gifford, whose level-headedness and ability to bring out the best in authors is as astonishing to me as is his ability to read and grasp a book in a matter of hours.
About the Author
Brian Goldman is an emergency physician at Toronto’s Mount Sinai Hospital and the host of CBC Radio’s award-winning program White Coat, Black Art. His inspiring yet bracingly honest TEDx talk about medical errors—which has been viewed on the Internet almost 1 million times—has cemented his reputation as one of his generation’s keenest observers of the culture of modern medicine. The author of the acclaimed book The Night Shift, Dr. Goldman lives in Toronto with his wife and two children.
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The Secret Language of Doctors
Copyright © 2014 by Brian Goldman Enterprises Ltd.
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